A. Complete Form SSA-1560A-U5 — Authorization to Charge and Collect a Fee

Use Form SSA-1560A-U5 (Authorization to Charge and Collect a Fee) (see
POMS
GN
03930.160A.) to notify the representative and the claimant of the fee
the Social Security Administration (SSA) authorized. Attach to the
SSA-1560-U5 a brief, but complete, explanation tailored to the
circumstances. (See B. below.)

Prepare a duplicate SSA-1560A-U5 when there is more than one family
unit.

To prepare Form SSA-1560A-U5:

Enter the identifying information (i.e., claimant's name, wage earner's
name (if different from the claimant's name), wage earner's Social
Security number, type of claim, and related Social Security number, if
any). If one or more auxiliary beneficiaries are involved, add “and
Family” after the claimant's name.

Enter the representative's name and address. If he/she is an attorney, use
one of the following with the address:

(Mr. or Ms.) (Name)Attorney at Law(Address)
(Name), Esq.(Address)

Enter the fee amount authorized after “You are authorized to charge
and collect a fee in the amount of $_____ ......” Make sure it
agrees with the amount finally authorized. Designate whether one or more
auxiliary beneficiaries are involved.

Enter the address to which a party must send any request for
administrative review as follows:

If Authorizer Is:

Fill in with:

Administrative Law Judge (ALJ)

Regional Chief ALJ's name (RCALJ who has jurisdiction over the claimant's servicing hearing office (HO)) and Regional Office address

Attorney Fee Branch (AFB)

Deputy Chair of the Appeals Council (AC) and the AC address

Designate the appropriate paragraph about the means of fee payment, if
available, as well as the reference to the attached notice.

Enter the authorizing official information and the name and address of the
claimant or auxiliary beneficiary(ies).

EXCEPTION:

Do not enter authorizing official information if you are recommending a
fee greater than $10,000.

Positive aspects Summarize those services that advanced the development of
the claim, or contributed significantly to a favorable determination. If
the authorized fee is greater than that requested, explain why it is
reasonable.

Neutral or negative aspects

Summarize those services:

that were not provided in proceedings before SSA;

that negatively affected the development of the claim;

the value of which is compromised because the time spent is unreasonable;
and/or

The fee authorizer may include the following sample paragraphs as
appropriate:

Retainer fee paid by claimant

Retainer fee is less than the authorized fee and there are withheld
benefits:

Because the claimant previously paid you a retainer fee of $____ for your
services and you are holding those funds in an escrow account, we will
send you the remaining balance out of the funds withheld from the
claimant's past-due benefits.

Retainer fee is less than the authorized fee and there are no withheld
benefits:

The claimant previously paid $___ towards your fee and you are holding
those funds in an escrow account. Therefore, the balance remaining for
your services is $____. You should look to the claimant for payment of the
balance.

Money in escrow account exceeds the authorized fee:

The claimant previously paid $____ towards your fee and you are holding
those funds in an escrow account. Because this amount exceeds the amount
of the fee you are authorized to collect, you must refund $____ to the
claimant.

Concurrent Title II and Title XVI Cases:

The fee approved is for all services performed in connection with both
claims.

State paid fee of known amount:

The amount you are authorized to charge for your services includes the fee
of $ (1) that the State of (2) paid or will pay you to
represent the claimant in a claim for benefits under title XVI of the
Social Security Act.

Fill-ins:

the amount of the State-paid fee

name of State that paid or will pay the fee.

State paid fee of unknown amount

We do not know the amount of the fee you received or will receive from the
State of (1) for representing the claimant in a claim for benefits
under title XVI of the Social Security Act. The amount you are authorized
to charge for your services includes any fee that the State of (1)
paid or will pay you.

Fill-in:

Name of State that paid or will pay a fee.

NOTE:

If the field office (FO) or processing center (PC) receives a fee
authorization without an explanation for the fee amount, that office may
return the fee authorization to the authorizer.

a. Title
II and/or title XVI Past-due Benefits Withheld for Direct Payment to a
Representative Eligible for Direct Fee Payment

Fax the following to the effectuating component (see I-1-2-114 (A.) for
the fax cover sheet and PC fax numbers):

claim file copy of the Form SSA-1560-U4, and

claim file copy of Form SSA-1560A-U5.

NOTE:

HOs and the AFB must use the fax numbers listed on the cover sheet at
I-1-2-114 (A.) when transmitting the completed Form SSA-1560A-U4 to the
PC. The receiving fax machine produces a digital image of the fee
authorization that the PC personnel can access from a personal
computer.

Important Information:

Other Government Websites:

Follow:

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